Training to be a surgeon takes too long in the UKBMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h3813 (Published 03 August 2015) Cite this as: BMJ 2015;351:h3813
- M Zeeshan Akhtar, MRC clinical research fellow, Nuffield Department of Surgery, University of Oxford
Surgical training in the UK takes far too long. Speeding it up could help tackle the health service’s shortage of surgeons, argues M Zeeshan Akhtar
As patient demand on the NHS increases, the need for more surgeons with greater operative and subspecialty exposure also rises. However, the current training system in the United Kingdom means that a typical surgical trainee will not finish higher surgical training until the age of 35-40. With most surgical trainees now pursuing a higher research degree, they could be even older by the time they are eligible to become a consultant.
I am a general surgical trainee with an interest in transplant and hepatobiliary surgery. I am 32, and after finishing medical school in 2007 I completed two years of foundation training followed by three years of core surgical training as an academic clinical fellow. I then did a PhD before entering higher surgical training.
By the time I have obtained my certificate of completion of training (CCT) I will be 38, not allowing for further specialist post-CCT fellowships and research training, both of which I hope to pursue. Over this time UK taxpayers will have invested hundreds of thousands of pounds in my training, but as I will be expected to retire from the NHS at the age of 66 my consultant career will be only 28 years long.
Not all surgical trainees will pursue an academic career as I have, but there is a strong argument that surgical training in the UK is too long. Despite attempts to modernise it over the years it is archaic in its approach, with progression still dependent on how much time a surgeon spends training rather than how competent they are.
If we were to fast track surgical trainees so that they achieved the necessary competencies by the age of 28-33, we could go some way to tackling the shortfall in surgeons, as well as creating opportunities for further subspecialty training. This would result in more highly trained surgeons who could have longer consultant careers in the NHS.
The US model shows that we could train surgeons in a shorter time frame. In the United States, training programmes in general surgery follow the format of a five year residency followed by a one to two year post-residency fellowship for subspecialty training. In this time surgical trainees will typically perform a similar number of operations to those performed by UK surgical trainees over an eight to nine year period. With the foundation programme the overall training period for a UK based surgeon is 10 to 12 years, compared with five to seven in the US.1
We need to ensure that trainees achieve the necessary operative experience. However, completing a sufficient number of procedures is hindered by several factors, including the use of shift based systems and the pressure on consultants to deal with waiting lists and publish outcomes.2 In addition, the number of trainees at the same level within the same system means that trainees have to share or fight for cases. These factors do not allow trainers and trainees to develop an apprentice-style relationship and put greater strain on operative lists.
High throughput training cannot be delivered in a 48 hour week. So, if we were to move towards a fast track system, trainees would need to put in more hours. Earlier selection of fewer surgical trainees into US residency-style programmes would enable trainees to perform more procedures and so achieve competency faster.
We also need to incentivise trainers and select programmes that encourage training. The development of stronger relationships between individual consultants and trainees would encourage the development of programmes that deliver more thoroughly trained and more competent surgeons.
There are major challenges to shortening the training programme, including service provision issues—for instance, who will put in the cannulas if the junior trainee is in theatre? Some would also argue that pushing surgeons too hard will result in mistakes through tiredness, and there will also be those who say that the general training obtained by foundation doctors and core trainees means they are more “rounded” doctors.
I wish I believed this, but in an increasingly specialised medical world the technical proficiency of a surgeon and their clinical judgment in surgery is what their skills will be judged on. Do we really need highly trained junior doctors putting in cannulas?
I believe that streamlining surgical training could tackle the attrition and dissatisfaction rates in surgery,3 leading to more highly trained surgeons, with greater subspecialty interest, and longer careers in the NHS. It’s time to shake up surgical training.
Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.